ALZIRA RIBERA SALUD How the Alzira model for integrated care achieves the best outcomes for it s citizens
What is the Alzira Model? A model of Integrated Care that started its life in 1993 when a new form of Private an Public Partnership (PPP) contract was agreed for Health Care in Spain Ribera Salud was the private company who was successful in bidding for this contract in the Valencia Region of Alzira The contract was to be for a period of 15 years with the option to extend for a further 5 years Outcomes have been improving ever since the inception of the model Based on population health and payment The basis of the model There are many parallels between the Alzira health system and the UK health model, both are free at the point of access and both are fully publically funded. The basis of the model is based on: Public Financing Based on a capitated payment The Government pays the provider a fixed and pre-established annual amount for each of its population. In Spain in 2015 this was 700 per inhabitant per annum This excludes drugs, oxygen therapy and ambulances Public Property The building / health Centre is built on public land and belongs to the government The building is built and maintained by the provider Public Control The provider is subject to complying with the established contract and monitored by the commissioner Private Provision The provision (both clinical and non-clinical) is awarded for a preestablished time to a provider In the Alzira Model it is for 15 years with the option to extend for a further 5 2
Current English model Ribera Salud Model Current Model of Care in England vs Ribera Salud Model Activity based model Contract counts activities and therefore there is an industry to demonstrate every bean has been counted and paid for Limited room for innovation as everyone is counting! Focuses on the need for more professionals, without recognition of other support staff development of clinical and non-clinical roles Increasing costs with increasing need doing more of the same, will get you more of the same! Does not promote health and prevent ill health and deterioration RESULT: NEED MORE, MORE and MORE Commitment to prevention Commitment to Health Promotion Encourage Innovation and sharing learning New buildings Money Follows the patient Core individual Health Number (SIP) like NHS Number Do what we have to do, in the most appropriate place 3
Core components as reflected by Ribera Salud to make it a success PPP Model To deliver the outcomes in the contract Ribera Salud have four key principles in delivery which deliver the outcomes defined in the contract and make the shareholders happy. These are: 1. Promoting Health 2. Improving Healthcare Quality 3. Improving Accessibility 4. Improving Efficiency Healthcare Integration There is an absolute focus on Population Health Management! Capitated Payment To achieve the best health conditions for the citizens The contract is designed to deliver 2 core outcomes: Highest possible Quality Care and health outcomes Value for Money and therefore keeping services in house by ensuring patient loyalty Networking The whole healthcare network, including the professionals within the provider and the other partners such as councils, schools, nursing homes etc all need to have a shared corporate culture! Culture Change is the most important factor, not the hospital! Best quality lies in not giving everything and not giving too much... What is best for patient regardless of the price... If it is the best possible option then give it, nothing worse than giving something when they don't need it... 4
Core ideas to consider Each Primary Care Doctor holds a case load of 1,800 patients at any one time: assigned clinician continuity is a key Care Primary Care is provided in large health centres with urgent care, some diagnostics and community care delivered from same centre Patients can choose with their feet! If a patient leaves Ribera Salud, then Ribera Salud have to foot the bill at any other provider All the Doctors are employed, but incentivised to drive the objectives Incentives Incentives are paid monthly to ALL staff There is no such thing as failure if there is a dip in performance a team supports the doctor to understand the reason for the variation There is no community service, but the community service team members (as we know of in England) are a part of the extended primary care team Structure All of this is only possible as the data infrastructure and systems have been fully embraced Model focuses on prevention of disease and delay of deterioration to keep costs down, but increase early detection and innovation 5
The success of Ribera Salud Clinical Management Do the correct intervention in the best place with the best quality and efficiency Chronic Health Plan Proactivity in Care Homecare, social and healthcare network Patient Safety Demand Management People Management Training, Teaching and Research Incentives systems aligned to delivery of core outcomes for every staff member Career and Professional Development Leads to high quality recruitment and retention No blame and no failure support for any that needs it Information Technology Full Electronic Patient Record Support Relationship between doctor and patients (Health Portal) Support Relationship between professionals (hospital and primary care) Business Intelligence System (including prevention) Benchmarking (cost analytics and what-if capabilities) 6
Kaiser Pyramid of Care Level 3: Immediate care needs Level 2: Risk Management Level 1: Self Care Level 0: Prevention Level 3 - Has a team of primary care and specialists around them, strong links with GP and Hospital Team, plus Nurse, Psychologist, Social Worker and whatever else is required. Patients have access to a 24/7 number of a call center run by a nurse. Primary care team immediately notified if patient has been to a specific part of the system and what the outcome was. Patient on Level 3 provides automatic consent! Level 1 and 2 make up 42.6% of the population - Focus on Self Management and LTC management Dementia, Hypertension, Diabetes, Obesity, Use of Tobacco and Alcohol Lot of push for patients to use e-tools and Health Portal to self-manage and link with professionals 35% of population now actively use the Health Portal to stay in touch with their GP Clinical Practice Guides published on the system to support the primary care team, with immediate access via the IT system or phone to specialist support when needed Level 0 makes up about 57.4% of the population. Prevention Programmes supported by Ribera Salud but targeted by Primary Care Team e.g. Women, Heart, Healthy Eating, Care Givers, Summer (rather than winter awareness campaigns), later life 7
Complexity Segmentation of patients Good Control Case Management Healthy Population Opportunities for efficiency Cost 8
How the IT system is used by a GP Each GP has access to the information on their cohort of patients for which he/she is responsible as well as at a population level. Examples of questions they answer using the IT system include: 1. What is my local population, how have they evolved 2. Age cohorts 3. Male/Female 4. Severity of illness (based on CRGs coding) 5. Where they are 6. Health Status of Diabetes 7. Find out patients who they do not have information for and then send a data list to the GP to follow up 8. Have a programme to identify patients who do not engage with GPs. The information is usually closer to a function the Public Health Teams in the UK perform, however, this is much more real time and under the responsibility of the GP to monitor and improve 9
The clinical perspective Outcomes not activity The most appropriate management plan is also the most efficient IT: real time data, shared, risk adjustments Personal list, continuity Primary TEAM Patient pathways include all providers Home care team Weekly MDT meetings 10
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